Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. (2012)

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1811

Assessment
The General Assessment of Personality Disorder
(GAPD) as an Instrument for Assessing the Core
Features of Personality Disorders
Han Berghuis,1* Jan H. Kamphuis,2 Roel Verheul,2,3 Roseann Larstone4
and John Livesley4
1
GGz Centraal Psychiatric Center, Hilversum, The Netherlands
2
University of Amsterdam, Amsterdam, The Netherlands
3
Viersprong Institute for Studies on Personality Disorders, Halsteren, The Netherlands
4
Department of Psychiatry, University of British Columbia, Vancouver, Canada

This study presents a psychometric evaluation of the General Assessment of Personality Disorder
(GAPD), a self-report questionnaire for assessing the core components of personality dysfunction on
the basis of Livesley’s (2003) adaptive failure model. Analysis of samples from a general (n = 196) and
a clinical population (n = 280) from Canada and the Netherlands, respectively, found a very similar
two-component structure consistent with the two core components of personality dysfunction proposed
by the model, namely, self-pathology and interpersonal dysfunction. Moreover, the GAPD discrimi-
nated between patients diagnosed with and without Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV-TR) personality disorder(s) and demonstrated discriminative power
in detecting the severity of personality pathology. Correlations with a DSM-IV symptom measure
and a pathological traits model suggest partial conceptual overlap. Although further testing is
indicated, the present findings suggest the GAPD is suitable for assessing the core components
of personality dysfunction. It may contribute to a two-step integrated assessment of personality
pathology that assesses both personality dysfunction and personality traits. Copyright © 2012 John
Wiley & Sons, Ltd.

Key Practitioner Message:

• The core features of personality disorder can be defined as disorders in the self and in the capacity for
interpersonal functioning.
• A clinically useful operationalization of disordered functioning of personality is needed to determine
the maladaptivity of personality traits.
• An integrated assessment of personality (dys)functioning and personality traits provides a more
comprehensive clinical picture of the patient, which may aid treatment planning.

Keywords: General Personality Disorder, Core Components of Personality Dysfunction, Personality

Assessment, General Assessment of Personality Disorder questionnaire

INTRODUCTION (Clark, 2007; Livesley, 2003; Trull & Durrett, 2005). Empir-
ical comparisons of categorical and dimensional models
The classification of personality disorder (PD) is in a state
consistently show that dimensional models fit the data
of flux. The current categorical model as presented in the
better and are more reliable (Livesley, Schroeder, Jackson
Diagnostic and Statistical Manual of Mental Disorders,
& Jang, 1994; Widiger, 1993; Trull & Durrett, 2005). This
Fourth Edition (DSM-IV-TR) is plagued by extensive diag-
has given way to discussion of how to incorporate
nostic overlap, poor coverage of the domain, considerable
dimensions into future classifications (Widiger, Livesley
diagnostic heterogeneity and minimal empirical support
& Clark, 2009). The proposals of the Personality and
Personality Disorder Workgroup for the DSM-5 PD
*Correspondence to: Han Berghuis, GGz Centraal Psychiatric Center, (American Psychiatric Association, 2010, 2011), which
P.O. Box 219, 1200 AE Hilversum, The Netherlands. advocates incorporating dimensions, can be seen as a
E-mail: [email protected] result of this discussion.

Copyright © 2012 John Wiley & Sons, Ltd.

 H. Berghuis et al.

Although adoption of a dimensional system would features and would almost certainly yield a diagnostic assess-
provide a much needed empirical foundation for classifying ment that is more useful for many purposes than a DSM-IV-
PD, an important question remains about how to differenti- TR diagnosis, there are problems with the underlying defin-
ate trait variations that constitute a disorder from statistical ition of PD. The approach entails a time-consuming task of
deviance, because statistical extremity alone is considered listing impairments or problems of living associated with
insufficient to diagnose a disorder (Parker & Barrett, 2000; the 60 poles of the 30 facet traits in the FFM, although an
Wakefield, 1992). An independent evaluation of distress or abbreviated version consisting of 26 facets is also suggested
impairment is therefore required (Trull, 2005). This paper (Widiger & Lowe, 2007). Although the proposed descriptors
proposes a systematic definition of PD that is conceptually appear reasonable, the empirical basis of the items listed is
independent of trait descriptions of PD and investigates unclear. More problematic from a definitional perspective,
whether such a definition may be used to construct an the problems that Wakefield (2008) noted in using
assessment instrument that differentiates PD from normal constructs such as ‘maladaptive’ and ‘clinically significant’
personality variation and from other mental disorders. as a way to characterize forms of trait expression are not
addressed. Using the global assessment of functioning
scale creates a further problem if DSM-5 will not employ
Definitions of Personality Disorder multiaxial classification as the Axis V would not be part of
the system.
Contemporary ideas about the nature of PD are strongly A more substantial problem of a pure trait model is
influenced by the DSM-III (American Psychiatric Associ- that it neglects the integrating and organizing aspects
ation, 1980) definition that PD consists of maladaptive of personality that are central to a broader conception of
traits. This generated extensive research into the trait personality (Allport, 1961; McAdams, 1996; Rutter, 1987).
structure of personality. The value of this approach is that As Millon (1996) noted, personality ‘is not a potpourri of
it is consistent with evidence that the phenotypic features unrelated traits and miscellaneous behaviors but a tightly
of PD are continuous with normal personality variation knit organization of stable structures (e.g., internalized
(Livesley et al., 1994; Widiger, 1993; Widiger & Simonsen, memories and self-images) and coordinated functions
2005; Trull & Durrett, 2005) and it begins to integrate the (e.g., unconscious mechanisms and cognitive processes).’
classification of PD with trait theories of personality It also involves the organization and coherence of the indi-
(Eysenck, 1987; Costa & Widiger, 2002; Widiger & Lowe, vidual (Cervone & Shoda, 1999). Similarly, PD as historic-
2007; Widiger & Simonsen, 2005; Widiger & Trull; 2007). ally described in the clinical literature is considered to
However, definition of PD in terms of maladaptive traits involve more than maladaptive traits (Livesley, 2003;
is complicated by the question of how to distinguish Livesley & Jang, 2000; Millon & Davis, 1996, Rutter,
normal and abnormal trait elevation. The usual way to 1987). Reference is also made to disturbed identity or
solve this problem is to require some additional factor self-pathology (Cloninger, 2000, Masterson & Klein,
such as maladaptive trait expression, clinical significance 1995; Kernberg, 1984), repetitive patterns of maladaptive
or inflexibility of trait expression in addition to trait eleva- interpersonal behaviour (Benjamin, 2003, Millon, 1981),
tion to justify a diagnosis of disorder. impaired social functioning (Rutter, 1987), impaired
The notion that traits which lie (very) high or (very) low motivation and self-directedness (Cloninger, 2000,
on various personality dimensions represent potential impaired metacognitive processes or mentalization
disorder is elaborated by Widiger and colleagues (e.g., (Bateman& Fonagy, 2004; Dimaggio, Semerari, Carcione,
Widiger & Mullins-Sweatt, 2009; Widiger & Trull, 2007). Procacci & Nicolò, 2006), the lack of adaptive capacities
They offer a four-step process approach to diagnosing PD (Verheul et al., 2008) and so on. Thus, the idea that
using the five-factor model (FFM). The first step is to maladaptive traits are a sufficient indicator of disorder is
describe personality using the 30 facet traits and five inconsistent with traditional clinical conceptions of
domains of the FFM. The second step is to ‘identify the personality (Wakefield, 2008).
problems of living associated with elevated scores’ (Widiger Problems with conceptualizing PD solely on the basis of
& Mullins-Sweatt, 2009, p. 201) or the social and occupa- maladaptive trait expression and desire to capture
tional impairments and distress associated with elevated dysfunction in the organizational or integrative aspects
scores (Widiger & Trull, 2007). The third step is to determine of personality have prompted suggestions that PD be
whether the problems of living (or ‘impairments’) reach defined independently of trait variation (Livesley et al.,
clinical significance. They propose that a useful guide for 1994; Trull & Durrett, 2005). Schneider (1923/1950)
making this determination is the global assessment of func- attempted to do this by defining PD as abnormal person-
tioning scale on Axis V of the DSM-IV-TR. The fourth ality that causes suffering to the self or society. The value
optional step is to match the FFM profile with prototypical of Schneider’s contribution is the distinction between
profiles of clinical diagnostic constructs such as the DSM- statistical abnormality and disorder, an idea that is funda-
IV-TR PDs. Although the proposal has many attractive mental to dimensional classification. Unfortunately, the

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

criteria proposed—suffering caused to self and society—are (2000), writing from a very different theoretical perspec-
subjective and value laden. An alternative formulation of tive, noted that low self-directedness—defined as a failure
functional impairment defines disorder as a failure of the of the motivational or agentic aspect of self or identity—is
adaptive functions of personality. This approach requires a a hallmark of PD. Finally, Verheul et al. (2008), in an
consideration of the functions of personality and how these attempt to develop a measure of the core features of PD,
functions are impaired in PD. Cantor (1990) suggested that suggested that a lack of identity integration—defined as
the adaptive function of personality is to solve major the coherence of identity and the ability to see oneself
personal and universal life tasks. Plutchik (1980) described and one’s own life as stable, integrated and purposive—
four universal tasks considered fundamental to adaptation is one of the most distinguishing characteristics of PD.
in the ancestral environment: (1) development of a sense
of identity; (2) solving problems of social hierarchy that
are characteristic of primate groups; (3) establishing Defining the Features of General Personality Disorder
territoriality and belongingness; and (4) coming to terms
with temporality involving problems of loss and separation. The first step in operationalizing the adaptive failure
The solutions to these tasks form important elements of conception of PD, and in developing a measure of PD
personality, and the failure to arrive at adaptive solutions (i.e.,the General Assessment of Personality Disorder
to any of these tasks gives rise to the harmful dysfunction [GAPD]: Livesley, 2006), was to conceptualize the two
that forms the core of PD (Livesley, 2003). main components of the definition: self and interpersonal
pathology. The self was conceptualized as a knowledge
system for organizing self-referential knowledge (Harter,
Personality Disorder as Adaptive Failure 1999; Toulmin, 1978; Livesley, 2003). This permitted a
description of self-pathology in terms of the cognitive
Livesley and colleagues (1994, 1998; Livesley and Jang, structure of self-knowledge rather than its contents
2000, Livesley, 2003) suggested that PD occurs when ‘the (self-schemas), an important step towards specifying PD
structure of personality prevents the person from achieving using constructs that are conceptually distinct from trait-
adaptive solutions to universal life tasks’ (Livesley, 1998, based behaviours. This is an important part of the
p. 141). This conceptualization can be expressed in more conceptualization of self-pathology that leads to a meas-
clinically relevant terms while retaining an evolutionary urement instrument that is designed to assess the formal
perspective as (1) failure to establish stable and integrated or structural aspects of the self, rather than distorted
representations of self and others and (2) interpersonal self-images or maladaptive schemas. It was assumed that
dysfunction, i.e., failures in the capacity for effective kinship the self-system, such as other knowledge structures,
and societal relations. To complete this definition, it is neces- develops through simultaneous processes of differenti-
sary to add that these deficits are enduring failures that can ation and integration. Throughout development, the
be traced to adolescence or early adulthood and that they differentiation of self-knowledge from other forms of
are not due to another pervasive and chronic mental knowledge begins to establish a boundary between self
disorder such as a cognitive or schizophrenic disorder. and others, and self-knowledge becomes organized into
This formulation attempts to integrate an understanding multiple self-schemas. At the same time, connections
of the adaptive functions of normal personality with clin- develop among self-schema to create different representa-
ical conceptions of PD. The clinical literature typically tions of the self. In the process, self-knowledge becomes
emphasizes that PD involves chronic interpersonal diffi- hierarchically organized as specific schemas combine
culties (Benjamin, 2003; Rutter, 1987; Vaillant & Perry, to construct different representations of the self. This
1980). Rutter (1987), e.g., concluded that PD is ‘character- process culminates in an overarching autobiographical
ized by a persistent, pervasive abnormality in social self-narrative that integrates the diverse aspects of
relationships and social functioning generally’ (p.454). A self-knowledge and self-experiences. These links within
second clinical tradition conceptualizes PD in terms of self-knowledge contribute to the subjective sense of
problems with identity or sense of self. Although this personal unity and continuity that characterizes an adap-
literature is largely, but not exclusively, confined to tive personality structure: the more extensive these links
psychoanalytic contributions, it has been extremely influ- are, the greater the sense of personal unity and coherence
ential with considerable impact on clinical conceptions of (Horowitz, 1998). Complementing these cognitive
PD, particularly as related to borderline and narcissistic constructs, the self was also conceptualized as a moti-
pathology. Examples are Kohut’s (1971) account of the vational or conative system on the basis of the literature
failure to develop a cohesive sense of self in narcissistic that considers the term ‘self’ to refer not only to the
conditions, Kernberg’s (1984) concept of identity diffusion organization of self-referential knowledge but also ‘to
and Masterson’s reconceptualization of PD as disorders of the more-or-less integrated center of agentic activity’
the self (Masterson & Klein, 1995). Similarly, Cloninger (Sheldon & Elliot, 1999, pp.483). A sense of direction,

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

purpose, agency and autonomy is a crucial component of and affiliation, whereas the societal component was divided
adaptive self-functioning (Carver & Scheier, 1998; Shapiro, into failure to establish the ability for prosocial behaviour
1981). Finally, the interpersonal component was also and problems with cooperativeness.
defined. Although this component of PD was more diffi- The third step in constructing the GAPD was to compile
cult to specify independently of trait content, it was items to assess the 15 facets of self-pathology and four
attempted by emphasizing pathology as the failure to facets of interpersonal dysfunction. Items were identified
develop specific interpersonal capacities as opposed to from a search of the clinical literature, culled from assess-
the form these failures take. These failures are conceptua- ment interviews and psychotherapy sessions with
lized as the failure to develop the capacity for intimacy patients with PD and written on the basis of the definition
and attachment, an inability to establish affiliative of the construct.
relationships and a disinterest in social contact. Dysfunc-
tions in societal relations concerned failures in the
capacity for prosocial, moral and cooperative behaviour. Current Study
The second step in developing a measure of PD (i.e., the
GAPD) was to use this conceptualization to structure an Although the literature points to the importance of defin-
assessment instrument to evaluate self and interpersonal ing PD in terms of dysfunction in the higher order
pathology. Self-pathology consisted of two main dimen- organization of personality, definitions based on abstract
sions (problems of differentiation and problems of integra- and generalized constructs raise concerns about whether
tion) and three additional facets of self-pathology such constructs can be measured reliably. This study was
(consequences of structural problems of the self). Problems designed to explore this issue. Four questions are
of differentiation, i.e. the range of schema used to repre- addressed. First, can the adaptive failure definition be
sent the self, were subdivided largely on the basis of used to develop a self-report measure that meets standard
rational considerations into five facets: poorly delineated psychometric criteria of an adequate psychological test?
interpersonal boundaries, lack of clarity or certainty Essentially, the definition consists of two components:
about self-attributes,sense of inner emptiness, context self-pathology and interpersonal dysfunction, both of
dependent self-definition (concept of self varies according which are complex multidimensional constructs. Compre-
to the perceived wants or expectations of others) and hensive assessment of them requires construction of
poorly differentiated representations of others (on the several subscales to evaluate different facets of self-
basis of general object relations theory, self-knowledge pathology and interpersonal pathology. Second, does the
was assumed to develop in the context of interpersonal facet structure of the subscales reflect the two-component
relationships). Problems of integration, or the extent to structure proposed in the definition and is this structure
which self-schemas are connected to form a coherent robust across clinical and general population samples?
understanding of the self, were organized into four facets: Third, does the measure discriminate between clinical
lack of sense of historicity and personal continuity, frag- samples with PD and general population samples and,
mentary self-representations and other-representations, importantly, between clinical samples with and without
self-state disjunctions (the occurrence of different poorly PD? The latter differentiation is important because it is
related self-states [Ryle, 1995; Horowitz, 1998]) and the necessary to demonstrate that the measure assesses PD
occurrence of a real self/false self-disjunction (Livesley, rather than general psychopathology and distress. Finally,
2003). Three additional facets of self-pathology were what is the relationship between components of general
defined on the basis of the clinical literature: lack PD and dimensions of PD as assessed by measures of
of authenticity, a defective sense of self (i.e., perception PD traits?
of the self as flawed) and a poorly developed understanding
of others (i.e., difficulty describing and understanding the
rules or grammar of behaviour [Livesley & Bromley, 1973],
a concept related to mentalization). The conative structure
of self-pathology or the self-directedness component was
METHODS
divided into three facets: lack of autonomy and agency, lack Participants
of meaning, direction, and purpose to life and difficulty
setting and attaining rewarding goals. The interpersonal Our two samples consisted of Canadian and Dutch partici-
component of PD was operationalized by emphasizing that pants. The Canadian group (n = 196) was a general popula-
pathology is the failure to develop specific interpersonal tion sample from the Vancouver, British Columbia area,
capacities as opposed to the form these failures take. These recruited through newspaper advertisements. These partici-
were conceptualized as the failure of kinship and societal pants completed the GAPD as part of an ongoing series of
functioning, respectively. Both were divided into two facets. studies investigating cognitive and motivational processes
The kinship component evaluated the capacity for intimacy underlying PD. This sample consisted of 64 men (32.7%)

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

and 132 women (67.3%), with a mean age of 37.9 years study (Zimmerman, Rothschild & Chelminski, 2005). We
(SD = 15.0, range = 18–76). utilized a cut-off of 10 diagnostic criteria for the definition
The Dutch sample (n = 280) consisted of a heterogeneous of PD not otherwise specified (Verheul, Bartak & Widiger,
group of psychiatric patients, composed of 78 men (28%) 2007). Nearly 70% (69.2%) met criteria for one or more
and 202 women (72%), with a mean age of 34.2 years comorbid Axis I disorders, the majority of which were
(SD = 11.7, range = 17–66). Education attainment varied as mood disorders (40.7%) or anxiety disorders (12.9%).
follows: 14.6% had completed elementary school/lower
vocational education, 38.2% secondary school/intermedi-
ate vocational training and 45.0% upper vocational educa- Measures
tion/university; for 2.2%, data were not available. Patients General Assessment of Personality Disorder
were invited to participate in the study by their treating The GAPD (Livesley, 2006) is a 144-item self-report
clinical psychologist or psychiatrist or completed a measure operationalizing the two core components of
questionnaire as part of a routine psychological evaluation. personality pathology proposed in Livesley’s (2003) adap-
All patients signed an informed consent form and received tive failure model. The primary scale Self-pathology covers
a €10 gift certificate for their participation. Patients with items regarding the structure of personality (e.g., problems
insufficient command of the Dutch language, with organic of differentiation and integration) and agency (e.g., conative
mental disorders or mental retardation, and patients in pathology). The primary scale Interpersonal dysfunction is
acute crisis were excluded. Table 1 shows the clinical charac- about failure of kinship functioning and societal function-
teristics of this sample. In 51.1% of the cases, at least one ing. These primary scales are divided into a total of 19
DSM-IV PD, as measured by the Structured Clinical Inter- subscales (15 for self-pathology and 4 for interpersonal
view for DSM-IV Axis II Personality Disorders (SCID-II; dysfunction). The definitions of the subscales of the GAPD
First et al., 1997), was reported. The most frequent Axis II are presented in Table 2. The present study used the original
diagnoses were borderline PD (18.9%), avoidant PD Canadian version and a Dutch translation (Berghuis, 2007).
(19.3%) and PD not otherwise specified (15.4%), a distribu- The original Canadian version was translated into Dutch
tion that is similar to that reported in a recent prevalence and then back translated by an English native speaker;
this version was subsequently approved by the original
Table 1. Clinical characteristics of the Dutch psychiatric sample author (J.L.). Of note, the Dutch translation differs from
(n = 280) the Canadian version in that the Canadian version
includes two additional questions that were added by
Characteristics n % the original test author (J.L.) after data collection had
Current DSM-IV Axis-I diagnosis †,{ already started in the Netherlands (item 12 from the
Mood disorder 114 40.7 Affiliation subscale and item 98 from the Difficulty
Anxiety disorder 36 12.9 setting and attaining goals subscale).
Eating disorder 16 5.7
Adjustment disorder 23 8.2
V-code 17 6.1 Structured Clinical Interview for DSM-IVAxis II
Other disorders 42 15.1 Personality Disorders
No Axis I disorder 32 11.4
The SCID-II (First et al., 1997; Weertman, Arntz &
Current DSM-IV Axis II diagnosis†,}
Paranoid personality disorder 19 6.8 Kerkhofs, 2000: Dutch version) is a widely used 119-item
Schizoid personality disorder 2 0.7 semi-structured interview for the assessment of Axis II
Schizotypal personality disorder 0 0.0 PDs. Each item is scored as 1 (absent), 2 (subthreshold) or
Antisocial personality disorder 14 5.0 3 (threshold). Dimensional scores are obtained by summing
Borderline personality disorder 53 18.9 the raw scores of the criteria for the Axis II categories and
Histrionic personality disorder 2 0.7 clusters. All SCID-II interviews were administered either
Narcissistic personality disorder 5 1.8
Avoidant personality disorder 54 19.3 by specifically trained clinicians with extensive experience
Dependent personality disorder 7 2.5 or by master-level psychologists who were trained by one
Obsessive–compulsive personality disorder 16 5.7 of the authors (H.B.) and who attended monthly refresher
Personality disorder NOS} 43 15.4 sessions to promote consistent adherence to study protocol.
Any personality disorder 143 51.1 Several studies have documented high interrater reliability
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth
of the SCID-II (e.g. Maffei et al., 1997 [from 0.83 to 0.98],
Edition. NOS = not otherwise specified. Lobbestael, Leurgans & Arntz, 2010 [from 0.78 to 0.91],
†
{
Individuals could be assigned more than one diagnosis. Dutch study). Therefore, no formal assessment of interrater
Clinical diagnosis. reliability was conducted. To further mitigate concerns
}
Structured Clinical Interview for DSM-IV Axis II Personality Disorders
diagnosis. about measurement error, we calculated internal consisten-
}
Cut-off: 10 criteria. cies for the SCID-II dimensional scores. Cronbach’s alphas

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

Table 2. Definitions of subscales of the General Assessment of Personality Disorder (GAPD)

GAPD Scale definition† Number of items

Primary scale: Self-pathology

Poorly delineated interpersonal boundaries Difficulty differentiating self from others; allows others to define 7
self experience; confuses others’ feelings with own.
Lack of self clarity Difficulty identifying and describing feelings and other experiences; 7
uncertain about personal qualities and characteristics.
Sense of inner emptiness Feels empty inside. 4
Context dependent self-definition Sense of self depends on who he or she is with; monitors others 5
carefully to decide how he or she should feel or act.
Poorly differentiated images of others Feelings about other people are disturbed; other people all look 4
the same.
Lack of history and continuity Feels as if he or she does not have a past; difficulty recalling 6
impressions of self only a few years ago; self-images are unstable
and change from day to day.
Fragmentary self-other representations Inconsistent and contradictory images and feelings about the self 11
and other persons; lacks a sense of wholeness; feels fragmented.
Self-state disjunctions Feels as if there are several different self-states; people tell them 5
that they change so much that it sometimes seems as if they are
a different person.
False self/real self disjunctions Feels as if the ‘real me’ is trapped inside and not able to get out; 6
when he or she talks about self, it feels as if he or she is
describing someone else.
Lack of authenticity Feelings and experiences feel unreal and not genuine; feels like a 7
fake or sham.
Defective sense of self Sense of being flawed, as if something is fundamentally wrong 3
with self.
Poorly developed understanding of Does not understand people at an intuitive level; does not have a 6
human behavior good sense of how to relate to other people.
Lack of autonomy and agency Unable to influence events or control own life and destiny. 5
Lack of meaning, purpose and direction Lacks a clear sense of direction; feels actions are purposeless and 7
pointless.
Difficulty setting and attaining goals Low self-directedness; derives little satisfaction from goal 8
attainment; has difficulty integrating goals with other parts of self.
Primary scale: Interpersonal dysfunction
Intimacy and attachment Impaired capacity for close intimate relationships of mutuality; 10
lacks capacity to form attachment relationships and to function
adaptively in attachment relationships; avoids attachments;
unable to tolerate someone being dependent on him or her.
Affiliation Inability to establish affiliative relationships; disinterest in social 9
contact; solitary and spends most time alone; inability to
establish friendships.
Prosocial Would never sacrifice self to help someone else; avoids helping 17
other people; does not see anything wrong with taking
advantage of someone who is easily conned
Cooperativeness Capacity to work together with other people, as part of a team. 15
†
Derived from: Livesley (2003). Practical management of personality disorders. pp. 121–122. Guilford Press: New York.

ranged from fair (0.57, schizotypal PD) to good (0.82, narcis- dysregulation, Compulsivity, Conduct problems, Identity
sistic PD), with a mean score of 0.71. problems, Insecure attachment, Intimacy problems,
Narcissism, Oppositionality, Rejection, Restricted expres-
sion, Self-harm, Social avoidance, Stimulus seeking,
Dimensional Assessment of Personality Pathology–Basic Submissiveness and Suspiciousness. The response format
Questionnaire (DAPP-BQ) is a five-point Likert scale ranging from 1 (‘very unlike
The DAPP-BQ (Livesley & Jackson, 2009; van Kampen me’) to 5 (‘very like me’). The DAPP-BQ is organized into
2006: Dutch version) is a 290-item questionnaire that four higher order clusters: Emotional dysregulation,
assesses 18-factor analytically derived PD trait scales: Dissocial, Social avoidance and Compulsivity. The psy-
Affective lability, Anxiousness, Callousness, Cognitive chometric properties of both the Canadian and Dutch

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

versions of the DAPP-BQ are well documented (Livesley parcels of the subscales (Table 3). Oblimin rotation was
& Jackson, 2009; van Kampen, 2006). used as we theorized that the underlying factors would
be related to an integrated model of core features of
Statistical Analysis personality pathology. Using parallel analysis, we
compared the average eigenvalues from the random
Means, standard deviations and internal consistencies correlation matrices with the eigenvalues from our data
(Cronbach’s alpha) were computed for the GAPD (sub) correlation matrix that yielded a cut-point of two factors
scales. The GAPD factor structure was investigated using as optimal solution in both samples. The two-factor solu-
principal component analysis with oblique (oblimin) tion explained 66.7% of the variance in the Canadian
rotation. Item parcels of the subscales were used as indica- sample (57.5% and 9.2%, respectively) and 65.0% of the
tors. Parallel analysis (Horn, 1965) was conducted to deter- variance in the Dutch sample (57.6% and 7.4%, respect-
mine the optimal number of factors to retain. The resulting ively). As shown in Table 3, the two-factor structure
solution was then evaluated and theoretically interpreted appeared remarkably consistent across samples. Almost
(Livesley, 2003). Subsequent analyses were conducted to all subscales of both the Canadian and Dutch versions of
test aspects of the convergent and discriminant validity the GAPD had the highest loadings on the factors to
of the GAPD using Pearson correlations, multivariate which they had been theoretically allocated in the original
analysis of covariance and discriminant function analysis. instrument. Only two subscales from the primary scale
All analyses were conducted using SPSS 17.0 for Windows Self-pathology showed substantial cross-loadings with
(SPSS Inc., Chicago, USA). the second factor (i.e., Poorly differentiated images of
others and Poorly developed understanding of human
behaviour). Primary loadings on both factors were overall
substantially higher than the secondary loadings (range
RESULTS difference scores 0.47–0.88), again except for the subscales
Factor Structure and Internal Consistency Poorly differentiated images of others and Poorly devel-
oped understanding of human behaviour (difference
To examine the factor structure of the GAPD, we scores 0.10 and 0.04 for the Canadian sample and 0.12
conducted a PCA with oblique (oblimin) rotation of item and 0.23 for the Dutch sample, respectively).

Table 3. Factor loadings of the subscales from the Canadian (n = 196) and Dutch (n = 280) General Assessment of Personality
Disorder (GAPD)

Canadian GAPD Dutch GAPD

Scale name Factor 1 Factor 2 Factor 1 Factor 2

Self-pathology
Poorly delineated boundaries 0.83 0.01 0.88 0.04
Lack of self clarity 0.88 0.05 0.88 0.01
Sense of inner emptiness 0.84 0.03 0.79 0.04
Context-dependent self-definition 0.80 0.31 0.85 0.19
Poorly differentiated images of others 0.43 0.33 0.35 0.47
Lack of historicity and continuity 0.89 0.05 0.88 0.04
Fragmentary self–other representations 0.85 0.07 0.78 0.14
Self-state disjunctions 0.80 0.01 0.85 0.11
False self-real self-disjunction 0.73 0.24 0.71 0.17
Lack of authenticity 0.82 0.15 0.81 0.12
Defective sense of self 0.77 0.11 0.65 0.16
Poorly developed understanding of human behaviour 0.45 0.41 0.31 0.54
Lack of autonomy and agency 0.80 0.03 0.70 0.09
Lack of meaning, purpose and direction 0.76 0.08 0.70 0.15
Difficulty setting and attaining goals 0.86 0.01 0.76 0.09
Interpersonal dysfunction
Intimacy and attachment 0.22 0.70 0.15 0.68
Affiliation 0.15 0.73 0.06 0.80
Prosocial 0.11 0.75 0.10 0.77
Cooperativeness 0.06 0.80 0.02 0.81

Direct oblimin rotation. Absolute loadings of 0.32 or greater were included on a component. Unique loadings are in bold. The Interpersonal dysfunction
subscales refer to maladaptive functioning (e.g., non-cooperativeness).

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

As can be seen in Table 4, Cronbach’s alpha from the seen in Table 5, all DAPP-BQ dimensions were signifi-
primary scales of the Canadian and Dutch GAPD ranged cantly related to the major domains of the GAPD, with the
from 0.93 to 0.98; the alphas of the subscales ranged from exception of Compulsivity in the Dutch sample and Stimu-
0.66 to 0.92 with a median of 0.86 for the Canadian GAPD lus seeking in the Canadian sample. Large correlations were
and from 0.70 to 0.90, with a median of 0.84 for the Dutch found between GAPD Self-pathology and DAPP-BQ Emo-
version. Means and standard deviations of the subscales tional dysregulation subscales in both samples (range
are also presented in Table 4. r = 0.53–0.88), with the exception of DAPP-BQ Narcissism
(r = 0.43 and 0.35) and Insecure attachment in the Canadian
sample (r = 0.39). For DAPP-BQ Dissocial Behaviour, all
Convergent and Discriminant Validity subscales were moderately associated with the two primary
scales of the GAPD in both samples, except DAPP-BQ
To test for convergent validity, we examined the relation- Callousness that showed a large correlation with GAPD
ship of the GAPD with conceptually relevant models: (1) Interpersonal dysfunction (r = 0.56 and 0.57). Of note are
the DSM model, employing symptom measure of PD, and the low correlations of DAPP-BQ Compulsivity with the
(2) the trait-based model of personality pathology that is GAPD primary scales in the Dutch sample.
operationalized by the DAPP-BQ. We computed Pearson Table 6 shows the means and standard deviations for the
correlations of the GAPD scales (i.e., Self-pathology and two primary scales of the GAPD (i.e., Self-Pathologyand
Interpersonal dysfunction) with the dimensional scores on Interpersonal dysfunction) for both the Canadian and
the SCID-II in the Dutch sample. Since not all PDs were Dutch samples in different groups. As the GAPD was
sufficiently represented, they were organized into clusters specifically designed to index general personality dysfunc-
A, B and C. All correlations were significant at the 0.01 level. tion, we reasoned that patients with more severe personal-
As expected, the associations between Self-pathology ity pathology should score higher than those with less
and Axis II were robust (r = 0.38, 0.39 and 0.38 for severe personality, who in turn should score higher than
clusters A, B and C, respectively). Interpersonal those without PD. To test this aspect of the discriminative
dysfunction also correlated with clusters A, B and C ability of the GAPD, we divided the Dutch patient sample
(r = 0.40, 0.21 and 0.28, respectively). into strata of severity of personality pathology. Severity of
The DAPP-BQ was selected as it operationalizes a personality pathology was based on the number of diag-
model of dysfunctional personality variation. As can be nosed PDs (none, one and two or more). The group without

Table 4. Means, standard deviations (SD), internal consistencies and number of items of the parcelled subscales of the Canadian
(n = 196) and Dutch (n = 280) General Assessment of Personality Disorder (GAPD)

Canadian GAPD Dutch GAPD

Scale name Items Mean SD Alpha Mean SD Alpha

Self-pathology 30.42 9.71 0.98 40.63 11.53 0.98

Poorly delineated boundaries 7 1.95 0.75 0.78 2.41 0.89 0.83
Lack of self clarity 7 2.28 0.96 0.89 3.23 1.06 0.87
Sense of inner emptiness 4 1.89 1.08 0.91 2.60 1.08 0.84
Context-dependent self-definition 5 2.46 0.88 0.78 2.86 0.96 0.80
Poorly differentiated images of others 4 1.98 0.73 0.66 2.15 0.80 0.70
Lack of historicity and continuity 6 2.05 0.91 0.87 2.56 1.01 0.86
Fragmentary self–other representations 11 2.32 0.69 0.88 2.60 0.82 0.87
Self-state disjunctions 5 2.02 1.00 0.86 2.33 0.98 0.81
False self/real self disjunction 6 2.08 1.01 0.90 3.18 1.07 0.87
Lack of authenticity 7 2.05 0.73 0.86 2.58 0.97 0.88
Defective sense of self 3 2.21 1.21 0.90 3.13 1.19 0.87
Poorly developed understanding of human behaviour 6 2.12 0.84 0.84 2.43 0.85 0.82
Lack of autonomy and agency 5 1.91 0.85 0.83 2.61 0.84 0.77
Lack of meaning, purpose and direction 7 2.63 0.42 0.92 3.11 1.02 0.90
Difficulty setting and attaining goals 9/8 2.53 0.78 0.89 2.86 0.89 0.85
Interpersonal dysfunction 9.44 1.87 0.94 9.39 2.32 0.93
Intimacy and attachment 10 2.08 0.80 0.86 2.38 0.86 0.85
Affiliation 10/9 2.29 0.90 0.90 2.54 0.94 0.89
Prosocial 17 2.44 0.37 0.88 2.03 0.51 0.81
Cooperativeness 15 2.63 0.34 0.85 2.45 0.58 0.85

The subscales of the Interpersonal dysfunction domain refer to maladaptive functioning.

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

Table 5. Correlations between the GAPD and the DAPP-BQ in a Canadian community sample (n = 196) and a Dutch psychiatric
sample (n = 246)

GAPD scales GAPD scales

Self- Interpersonal Self- Interpersonal
pathology dysfunction pathology dysfunction

Canadian DAPP-BQ scales Dutch DAPP-BQ scales

Emotional disturbance Emotional disturbance
Submissiveness 0.64** 0.27** Submissiveness 0.57** 0.29**
Cognitive distortion 0.82** 0.50** Cognitive distortion 0.77** 0.53**
Identity problems 0.88** 0.50** Identity problems 0.85** 0.57**
Affect lability 0.63** 0.28** Affect lability 0.64** 0.38**
Oppositionality 0.75** 0.48** Oppositionality 0.62** 0.38**
Anxiousness 0.76** 0.36** Anxiousness 0.79** 0.44**
Social avoidance 0.67** 0.62** Social avoidance 0.72** 0.62**
Suspiciousness 0.54** 0.43** Suspiciousness 0.64** 0.53**
Insecure attachment 0.39** 0.16* Insecure attachment 0.56** 0.23**
Narcissism 0.35** 0.07 Narcissism 0.43** 0.22**
Self-harm 0.69** 0.46** Self-harm 0.53** 0.33**
Dissocial behaviour Dissocial behaviour
Stimulus seeking 0.31** 0.12 Stimulus seeking 0.45** 0.30**
Callousness 0.33** 0.57** Callousness 0.42** 0.56**
Rejection 0.15* 0.19** Rejection 0.24** 0.33**
Conduct problems 0.42** 0.40** Conduct problems 0.35** 0.40**
Inhibitedness Inhibitedness
Restricted expression 0.50** 0.61** Restricted expression 0.60** 0.56**
Intimacy 0.34** 0.21** Intimacy 0.38** 0.51**
Compulsivity 0.17* 0.20** Compulsivity 0.03 0.05
GAPD = General Assessment of Personality Disorder. DAPP-BQ = Dimensional Assessment of Personality Pathology–Basic Questionnaire.
**Correlation is significant at the 0.01 level.
*Correlation is significant at the 05 level (two-tailed). Correlations above 0.50 are printed in bold.

Table 6. The association between GAPD factor scale scores and the number of diagnosable personality disorders per patient (n = 280)

General population Number of diagnosable personality

Canadian sample disorders Dutch sample

Factor (n = 196) 0-PD (n = 137) 1-PD (n = 96) 2+-PD (n = 47) F(2, 276) Post-hoc test Effect size
Self-pathology 30.42 (9.7) 35.66 (10.9) 43.28 (10.1) 50.06 (8.3) 34.54* 0 < 1 < 2+** 0.73†; 0.73{, 1.49}
Interpersonal 9.44 (1.9) 8.49 (2.2) 9.79 (2.3) 10.42 (2.1) 15.07* 0 < 1, 2+** 0.57†; 0.28{, 0.90}
dysfunction

GAPD = General Assessment of Personality Disorder. 0-PD = no personality disorder. 1-PD = one personality disorder. 2+-PD = 2 or more personality
disorders. The data in the general population and the number of diagnosable personality disorders columns are the mean scores (standard deviations).
†
Cohen’s d effect size of the difference between the 0-PD group and the 1-PD group.
{
Cohen’s d effect size of the difference between the 1-PD group and the 2+-PD group.
}
Cohen’s d effect size of the difference between the 0-PD group and the 2+-PD group.
*p < 0.001.
**p < 0.01.

PDs consisted of patients in treatment for other psychiatric on the primary GAPD components. Cohen’s d was calcu-
problems or disorders. These three groups did not differ lated for the group differences. There was a medium
with respect to gender (X2 = 0.57, p = 0.75) but differed in effect size for the difference on Self-pathology and
age (F(2, 277) = 5.45, p = 0.01). Age influenced group differ- Interpersonal dysfunction (d = 0.73 and 0.57,
ences only on the Self-pathology factor (F(1, 276) = 6.48, respectively) between the no-PD and one PD groups.
p = 0.01), such that the scores on the Self-pathology factor Medium to small effect sizes for the difference on
declined with age. Self-pathology and Interpersonal dysfunction (d = 0.73
As can be seen in Table 6, severity of personality and 0.28, respectively) were found between the group
pathology significantly corresponded with higher scores with one and the group with two or more PDs

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

(d = 0.57 and 0.28, respectively). Large effect sizes for pathology and Interpersonal dysfunction of the GAPD.
the difference on Self-pathology and Interpersonal A comparable structure of the core features of personality
dysfunction (d = 1.49 and 0.90, respectively) were pathology has also been found in other studies. Verheul
observed between the no-PD group and the group with et al. (2008) investigated the core components of personal-
two or more PDs. To facilitate comparison with future ity dysfunction and proposed that in addition to the
studies, Table 6 presents the non-adjusted means; age- conceptually similar domains of Identity integration, Rela-
adjusted means differed only in decimals. tional capacities and Social concordance, Self-control and
A discriminant function analysis was performed on Responsibility may also be identified as higher order
the entire clinical group (n = 280) with the presence or domains of disturbed personality functioning. A third
absence of PD as the dependent variable and the scores model by Parker and colleagues (Parker, Hadzi-Pavlovic,
on the primary GAPD scales as the independent vari- Both, Kumar, Wilhelm & Olley, 2004) as well as the model
ables. The value of this function was significantly by Cloninger (2000) posits that deficits in Cooperativeness
different for the no-PD and any-PD group (X2 = 56.32, and Coping or Self-directedness form the higher order
degrees of freedom [df] = 2, p < 0.001). Overall, the structure of the construct defining disordered personality
discriminant function analysis classified 68.8% of the function. Taken together, some theoretical convergence is
participants correctly as PD or no-PD patients. This notable such that the domains of Self-pathology, Self-
represents an increase of 17.8% in accuracy, assuming directedness, Coping, Interpersonal Functioning and
an a priori chance of 51% on the basis of the base rate of Cooperativeness are considered core factors of disordered
our sample. On the basis of the discriminant function personality functioning across a variety of studies and
analysis, the sensitivity (proportion of the any-PD group, perspectives. However, although the above factors show
correctly classified as such) was 0.71 and specificity (propor- content overlap, they are not identical. Future research
tion of the no-PD group, correctly classified as such) of the should investigate the ways in which the GAPD is related
GAPD was 0.66, respectively. to other models.

Discriminatory Power of the GAPD

DISCUSSION
Structure of the Canadian and the Dutch Versions of Since the GAPD was developed in the context of the
the GAPD discussion on categorical and dimensional classifications
of PDs, it is significant that the GAPD was able to differen-
The present study is the first to examine the GAPD as a tiate between patients with and without categorical PD.
self-report questionnaire operationalizing Livesley’s The primary GAPD scales also differentiated between
(2003, 2007) adaptive failure model. One of the main levels of severity of personality pathology. These findings
findings is the highly similar factor structure of the suggest the possibility of using GAPD scores for the deriv-
Canadian GAPD and its Dutch counterpart. The factor ation of (multiple) cut- points for determining (degree of)
structure was not only remarkably consistent across pathology on the basis of severity of symptoms and
these cross-national samples but was also congruent dysfunction (Helzer, Kraemer & Krueger, 2006; Kamphuis
with the two primary scales of the original instrument. & Noordhof, 2009). Such cut-points would go beyond
These findings can be seen as an initial cross-national mere statistical criteria as they are underpinned by theo-
validation of the underlying adaptive failure model. retical constructs and a coherent conceptual rationale. This
The multidimensionality of the Self-pathology and is relevant to clinical practice because linking pathology to
Interpersonal dysfunction scales was shown in the a theoretical meaningful framework increases clinical
subscale reliabilities. Moreover, the primary scales were utility (Shedler & Westen, 2004; Verheul, 2005).
consisted of subscales that demonstrated good internal The GAPD also appears to differentiate between
consistency. patients and non-patients. This finding is notable because
the GAPD putatively measures specific dysfunction of
personality rather than general emotional impairment or
Models of Personality Dysfunction and the GAPD psychosocial dysfunction. Of course, these concepts are
inherently related, an association that has also been
In Livesley’s adaptive failure model, personality dysfunc- observed by others. For example, Ro and Clark (2009)
tion is seen as a failure of adaptation in relevant life described the importance of psychosocial dysfunction in
domains, especially those concerning establishing a stable, diagnosis of PD and acknowledged the conceptual
coherent sense of self and identity and developing overlap between trait measures, personality and social
prosocial patterns of interpersonal behaviour. These com- functioning and psychosocial functioning. In their study,
ponents are operationalized in the primary scales Self- scales related to personality functioning (in particular,

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

identity) loaded onto the same factor as scales related to unidimensional construct specific to a particular PD
subjective well-being, suggesting conceptual overlap. (perhaps obsessive–compulsive PD). In support of this
However, their study found a clear interpersonal and conjecture are the findings by Verheul et al. (2008), who
social functioning factor, as did ours. Since general also reported low correlations of the DAPP-BQ Compul-
emotional impairment is also expected in patients with sivity scale with subscales of another measure of the core
only Axis I pathology, we believe our finding that the components of personality (dys)functioning (i.e., the
GAPD discriminated between patients with and patients Severity Indices of Personality Problems-118). Further-
without a PD indicates that more than just general more, the related normal personality trait of Conscien-
pathology or distress is measured. Clearly, more research tiousness (NEO-PI-R) has been shown to be specifically
is needed to examine the degree to which these concepts related to unique PDs rather than to general personality
can be optimally disentangled. pathology (see Saulsman & Page, 2004).

Dimensions of Personality Disorders and the GAPD Limitations

The GAPD scales were related to both the SCID-II dimen- The current study is limited by some of its sampling proper-
sional score and the DAPP-BQ scales. Associations were ties. Not all PDs were represented in the Dutch psychiatric
of about equal strength with each of the Axis II clusters, sample, and its unequal gender distribution (although not
suggesting that the GAPD measures general personality unusual in such psychiatric samples) should be taken into
pathology rather than a specific type. account when generalizing our findings. For the analysis
The Self-pathology scale of the GAPD and the Emo- of structure, we consider our cross-national sample strategy
tional dysregulation domain of the DAPP-BQ were most a strength, and the highly similar psychometric properties
closely related in both samples of our study. Emotional and principal components that emerged for the Dutch and
dysregulation represents unstable and reactive tendencies, Canadian versions of the GAPD suggest a robust structure.
problems with identity and self-esteem and interpersonal However, one cannot directly compare means across
problems. Since the DAPP-BQ is an instrument for the samples as they differ not only in clinical status (normal
assessment of ‘pathological’ personality traits (i.e., cover- versus clinical subjects) but also in nationality. Future
ing the maladaptive range of personality functioning), it studies may elucidate to what extent clinical and normal
is not surprising that these concepts are strongly related. subjects differ within countries.
Traits have a widespread impact on all aspects of personal- Limitations with regard to the measurements are the
ity, and hence, it is inevitable that trait measures will exclusive reliance on self-report measures for the assess-
correlate with measures of core personality dysfunction, ment of personality dysfunction and personality traits,
such as GAPD scores. In addition, the multidimensionality and the absence of formal interrater reliability data for
of traits, especially Emotional Dysregulation, contributes the SCID-II ratings. The limitations of self-report instru-
to conceptual overlap between trait models and models ments are extensively discussed (e.g., Ganellen, 2007),
of personality dysfunctioning. Berghuis, Kamphuis and and it has been suggested that there are limitations in
Verheul (2012) recently not only documented related the capacity for psychological insight and awareness in
meaningful associations between the GAPD and the patients with personality pathology (Westen & Shedler,
NEO Personality Inventory–Revised (NEO-PI-R) (as a 2000). We recognize this as an important general issue,
measurement of ‘normal’ personality traits [Costa & and we also note that the issue requires systematic empir-
McCrae, 1992]) but also demonstrated in a joint factor ana- ical analysis, but consider it beyond the focus of the
lysis that components of general personality dysfunction- present paper. We point out that the use of self-reports is
ing (GAPD) and particular facets of specific personality a widely used method in both PD research and clinical
traits (NEO-PI-R) were factorially distinct. As the DSM-5 practice, and choose here to focus on the specific contribu-
Personality and Personality Disorders Workgroup (American tion self-report instruments may make in emerging
Psychiatric Association, 2010, 2011) is proposing a model models of personality pathology. We derive some encour-
of PD assessment and classification containing concepts agement from the observation that the GAPD differen-
related to personality dysfunction and personality traits, tiated PD from both normal personality and from other
it is important that the distinction between these two mental disorders. Moreover, we consider the use of
concepts and their operationalization across measurement structured interview (SCID-II) based rating of symptoms
methods (e.g., self-report measures and diagnostic inter- of DSM-IV PDs in this context also as a strength, as it
views) are further investigated. bypasses method variance inflated correlations.
Of note are the minimal correlations between the DAPP- As previously suggested, the nature of the relationship
BQ Compulsivity scale and the primary scales of the of the GAPD with other related models and measures
GAPD. The DAPP-BQ Compulsivity domain may tap a requires further exploration. Further research may also

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

reveal to what extent the GAPD may be useful for screen- Allport, G.W. (1961). Pattern and growth in personality. New York:
ing purposes for the detection of general personality Holt, Rinehart & Winston.
Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline
pathology. For such an application, it would be imperative
personality disorder. Oxford: Oxford University Press.
for the questionnaire to distinguish reliably PD cases from Benjamin, L.S. (2003). Interpersonal diagnosis and treatment of
non-cases and to demonstrate high specificity to detect personality disorders. New York: the Guilford Press.
comorbidity between Axis I and II. Berghuis, H. (2007). General assessment of personality disorder
In conclusion, we present the GAPD as a promising (GAPD). Version 2007. Amersfoort: Symfora groep.
operationalization of a conceptually coherent model of Berghuis, H., Kamphuis, J.H., & Verheul, R. (2012). Core features
maladaptive personality functioning. This instrument of personality disorder: Differentiating general personality
dysfunctioning from personality traits. Journal of Personality
may contribute to the discussions about the nature of the Disorders, 26, 28. DOI: 10.1521/pedi.2012.26.028
DSM-5 PD representation. In the successively proposed Cantor, N. (1990). From thought to behavior: “Having” and
DSM-5 models (APA, 2010, 2011), personality (dys)func- “doing” in the study of personality and cognition. The American
tion is part of the assessment of PD. Moreover, a consistent Psychologist, 45, 735–750. DOI: 10.1037/0003-066X.45.6.735
part of the proposals is the revised general criteria for PD Carver, C.S., & Scheier, M.F. (1998). On the self-regulation of
that would specify significant impairment in personality behavior. Cambridge, UK: Cambridge University Press.
functioning manifested by impairment in self-functioning Cervone, D., & Shoda, Y. (1999). Social-cognitive theories and
coherence of personality. In D. Cervone, & Y. Shoda (Eds.),
and interpersonal functioning. This is the first diagnostic The coherence of personality (pp. 3–33). New York: Guilford
criterion. The GAPD primary scales are very similar to Press.
these criteria and could therefore be used as indices for Clark, L.A.. (2007). Assessment and diagnosis of personality
that criterion. disorder: Perennial issues and an emerging reconceptualiza-
More generally, the GAPD may be used in a similar, tion. Annual Review of Psychology, 58, 227–257. DOI: 10.1146/
previously described two-step diagnostic procedure for annurev.psych.57.102904.190200
the assessment of PD (Livesley, 2003; Pincus, 2005). In Costa, P.T., & McCrae, R.R. (1992). Revised NEO personality
inventory (NEO-PI-R) and the five factor inventory (NEO-FI):
such procedures, the definition of PD pathology is distin- Professional manual. Odessa, Florida: Psychological Assessment
guished from the description of individual differences in Resources Inc.
the phenomenology of PD. The GAPD can be used as an Costa, P.T. Jr., & Widiger, T.A. (2002). Personality disorders and
instrument to define disordered functioning from a the five-factor model of personality (2nd Ed.). Washington, DC:
categorical perspective but should probably be supple- American Psychological Association.
mented by additional assessment instruments when a Cloninger, C.R. (2000). A practical way to diagnose personality
disorder: A proposal. Journal of Personality Disorders, 14,
formal clinical diagnosis of PD is needed. In a second step,
99–108. DOI: 10.1521/pedi.2000.14.2.99
other instruments such as the DAPP-BQ can provide a Dimaggio, G., Semerari, A., Carcione, A., Procacci, M., & Nicolò,
descriptive dimensional picture of the person. The G. (2006). Toward a model of self pathology underlying
combination of these perspectives may lead to an inte- personality disorders: Narratives, meta representation,
grated assessment approach of personality pathology interpersonal cycles and decision-making processes. Journal
(Huprich, Bornstein & Schmitt, 2011; Stepp et al., 2012), of Personality Disorders, 20, 597–617. DOI: 10.1521/pedi.2006.
in which the integration of multiple perspectives on 20.6.618
Eysenck, H.J. (1987). The definition of personality disorders
personality traits and personality pathology and multiple and the criteria appropriate for their description. Journal of
relevant instruments is used in the assessment of person- Personality Disorders, 1, 211–219. DOI: 10.1521/pedi.1987.1.
ality and PD. This integrated assessment approach may 3.211
yield a more comprehensive understanding of PD First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B.W., & Benjamin,
patients, which presumably will be conducive to high- L. (1997). Structured clinical interview for DSM-IV axis II person-
quality treatment planning. ality disorders (SCID-II).
Ganellen, R.J. (2007). Assessing normal and abnormal personality
functioning: Strengths and weaknesses of self-report, observer
and performance-based methods. Journal of Personality Assess-
ment, 89, 30–40. DOI: 10.1080/00223890701356987
REFERENCES Harter, S. (1999). The construction of the self. New York:
Guilford Press.
American Psychiatric Association (1980). Diagnostic and statis- Helzer, J.E., Kraemer, H.C., & Krueger, R.F. (2006). The feasibility
tical manual of mental disorder (3rd ed.). Washington, DC: and need for dimensional psychiatric diagnoses. Psychological
American Psychiatric Press. Medicine, 36, 1671–1680. DOI: 10.1017/S003329170600821
American Psychiatric Association (2010, 2011). DSM-5 develop- Horn, J.L. (1965). A rationale and test for the number of factors in
ment. Versions February, 2010, January, and June, 2011. factor analysis. Psychometrika, 30, 179–185.
Retrieved May, 29, 2010, February, 14, 2011, and August,1 Horowitz, M.J. (1998). Cognitive psychodynamics. New York: Wiley
2011 from the American Psychiatric Association Website: and Sons.
http://www.dsm5.org/ProposedRevisions/Pages/Personali- Huprich, S.H., Bornstein, R.F., & Schmitt, T.A. (2011). Self-report
tyandPersonalityDisorders.aspx. methodology is insufficient for improving assessment and

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
GAPD

classification of axis-II personality disorders. Journal of Person- Parker, G., & Barrett, E. (2000). Personality and personality dis-
ality Disorders, 25, 557–570. DOI: 10.1521/pedi.2011.25.5.557 order: Current issues and directions. Psychological Medicine,
van Kampen, D. (2006). The Dutch DAPP-BQ: Improvements, 30, 1–9.
lower- and higher-order dimensions, and relationship with Parker, G., Hadzi-Pavlovic, D., Both, L., Kumar, S., Wilhelm,
the 5DPT. Journal of Personality Disorders, 20, 81–101. DOI: K., & Olley, A. (2004). Measuring disordered personality
10.1521/pedi.2006.20.1.81 functioning: To love and work reprised. Acta Psychiatrica
Kamphuis, J.H., & Noordhof, A. (2009). On categorical diagnosis Scandinavica, 110, 230–239. DOI: 10.1111/j.1600-0447.
in DSM-V: Cutting dimensions at useful points?. Psychological 2004.00312.x
Assessment, 21, 294–301. DOI: 10.1037/a0016697 Pincus, A.L. (2005). A contemporary integrative interpersonal theory
Kernberg, O.F. (1984). Severe personality disorders. New Haven, of personality disorders. In J.F. Clarkin, & M.F. Lenzenweger
CT: Yale University Press. (Eds.), Major theories of personality disorder (2nd ed., pp.282-331).
Kohut, H. (1971). The analysis of the self. New York: International New York: Guilford Press.
Universities Press. Plutchik, R. (1980). A general psycho evolutionary theory of
Livesley, W.J. (1998). Suggestions for a framework for an empiric- emotion. In R. Plutchik, & H. Kellerman (Eds.), Emotion,
ally based classification of personality disorder. Canadian Jour- psychopathology, and psychotherapy (pp. 3–33). New York:
nal of Psychiatry, 43, 137–147. Academic Press.
Livesley, W.J. (2003). Practical management of personality disorders. Ro, E., & Clark, L.A. (2009). Psychosocial functioning in the context
New York: Guilford Press. of diagnosis: Assessment and theoretical issues. Psychological
Livesley, W.J. (2006). General assessment of personality disorder Assessment, 21, 313–324. DOI: 10.1037/a0016611
(GAPD). Department of Psychiatry, University of British Rutter, M. (1987). Temperament, personality, and personality
Columbia. disorder. The British Journal of Psychiatry, 150, 443–458.
Livesley, W.J. (2007). A framework for integrating dimensional Ryle, A. (Ed.) (1995). Cognitive analytic therapy. Chichester,
and categorical classifications of personality disorder. Journal England: John Wiley & Sons.
of Personality Disorders, 21, 199–224. DOI: 10.1521/ Saulsman, L.M., & Page, A.C. (2004). The five-factor model and
pedi.2007.21.2.199 personality disorder empirical literature: A meta-analytic
Livesley, W.J., & Bromley, D.B. (1973). Person perception in child- review. Clinical Psychology Review, 23, 1055–1085. DOI: org/
hood and adolescence. Chichester: Wiley. 10.1016/j.cpr.2002.09.001
Livesley, W.J., & Jackson, D.N. (2009). Manual for the dimensional Schneider, K. (1923/1950). Psychopathic personalities (9th ed.).
assessment of personality pathology – basic questionnaire (DAPP-BQ). London: Cassell.
Port Huron, MI: Sigma Assessment Systems. Shapiro, D. (1981). Autonomy and rigid character. New York: Basic
Livesley, W.J., & Jang, K.L. (2000). Toward an empirically based Books.
classification of personality disorder. Journal of Personality Shedler, J., & Westen, D. (2004). Refining personality disorder
Disorders, 14, 137–151. DOI: 10.1521/pedi.2000.14.2.137 diagnosis: Integrating science and practice. The American Jour-
Livesley, W.J., Jang, K.L., & Vernon, P.A. (1998). The phenotypic nal of Psychiatry, 161, 1350–1365. DOI: 10.1176/appi.
and genetic structure of traits delineating personality disorder. ajp.161.8.1350
Archives of General Psychiatry, 55, 941–948. DOI:10-1001/pubs. Sheldon, K.M., & Elliot, A.J. (1999). Goal striving, need satisfac-
Arch Gen Psychiatry-ISSN-0003-990x-55-10-yoa7424 tion, and longitudinal well-being: The self-concordance model.
Livesley, W.J., Schroeder, M.L., Jackson, D.N., & Jang, K.L. (1994). Journal of Personality and Social Psychology, 76, 482–497. DOI:
Categorical distinctions in the study of personality disorder: 10.1037/0022-3514.76.3.482
Implications for classification. Journal of Abnormal Psychology, Stepp, S.D., Lan Y., Miller, J.D., Hallquist, M.N., Trull, T.J., & Pilkonis,
103, 6–17. DOI: 10.1037/0021-843X.103.1.6 P.A. (2012). Integrating competing models of personality: Linking
Lobbestael, J., Leurgans, M., & Arntz, A. (2010). Inter-rater re- the SNAP, TCI, and NEO using item response theory. Personality
liability of the Structured Clinical Interview for DSM-IV Disorders: Theory, Research and Treatment, 3, 107–126. DOI:
Axis I Disorders (SCID I) and Axis II Disorders (SCID II). 10.1037/a0025905
Clinical Psychology & Psychotherapy, 18, 75–79. DOI: 10.1002/ Toulmin, S. (1978). Self-knowledge and knowledge of the “self.”
cpp.693 In T. Mischel (Ed.), The self: Psychological and philosophical issues
Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., (pp.291-317). Oxford: Oxford University Press.
Deborah, D., Namia, C., Novella, C. & Petrachi, M. (1997). Trull, T. (2005). Dimensional models of personality disorder: Cover-
Interrater reliability and internal consistency of the structured age and cutoffs. Journal of Personality Disorder, 19, 262–282. DOI:
clinical interview for DSM-IV axis II personality disorders 10.1521/pedi.2005.19.3.262
(SCID-II), version 2.0. Journal of Personal Disorders, 11, 279–284. Trull, T., & Durrett, C.A. (2005). Categorical and dimensional
DOI: 10.1521/pedi.1997.11.3.279 models of personality disorder. Annual Review of Clinical
Masterson, J.F., & Klein, R. (1995) (Editors), Disorders of the self. Psychology, 1, 355–380. DOI: 10.1146/annurev.clinpsy.1.
Leittown, PA: Brunner/Mazel. 102803.144009
McAdams, D.P. (1996). Personality, modernity, and the storied Vaillant, G.E., & Perry, J.C. (1980). Personality disorders. In H.I.
self: A contemporary framework for studying persons. Psycho- Kaplan, A.M. Freedman, B.J Sadock (Eds.), Comprehensive text-
logical Inquiry, 7, 295–321. DOI: 10.1207/s15327965pli0704_1 book of psychiatry/III (Volume Two; pp. 1562–1590). Baltimore:
Millon, T. (1981). Disorder of personality: DSM-III axis II. New Williams & Wilkins.
York: Wiley. Verheul, R. (2005). Clinical utility of dimensional models for per-
Millon, T. (1996). Personality and psychopathology. New York: sonality pathology. Journal of Personality Disorders, 19, 283–302.
Wiley. DOI: 10.1521/pedi.2005.19.3.283
Millon, T., & Davis, R. (1996). Disorders of personality: DSM-IV and Verheul, R., Bartak, A., & Widiger, T. (2007). Prevalence and
beyond. New York: Wiley. construct validity of personality disorder not otherwise

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp
 H. Berghuis et al.

specified (PDNOS). Journal of Personality Disorders, 21, 359–370. Widiger, T.A. (1993). The DSM-III-R categorical personality dis-
DOI: 10.1521/pedi.2007.21.4.359 order diagnosis: A critique and alternative. Psychological
Verheul, R., Andrea, H., Berghout, C., Dolan, C.C., Busschbach, Inquiry, 4, 75–90. DOI: 10.1207/s15327965pli0402_1
J.J.V., Van der Kroft, P.J.A., Bateman, A.W., & Fonagy, P. Widiger, T.A., Livesley, W.J., & Clark, L.A. (2009). An integrative
(2008). Severity indices of personality problems (SIPP-118): dimensional classification of personality disorder. Psychological
Development, factor structure, reliability and validity. Assessment, 21, 243–255. DOI: 10.1037/a0016606
Psychological Assessment, 20, 23–34. DOI: 10.1037/1040- Widiger, T.A., & Lowe, J.R. (2007). Five-factor model assessment
3590.20.1.23 of personality disorder. Journal of Personality Assessment, 89,
Wakefield, J.C. (1992). The concept of mental disorder: On the 16–29. DOI: 10.1080/00223890701356953
boundary between biological facts and social values. The Widiger, T.A., & Mullins-Sweatt, S.N. (2009). Five-factor model of
American Psychologist, 47, 373–388. DOI: 10.1037/0003- personality disorder: A proposal for DSM-V. Annual Review of
066X.47.3.373 Clinical Psychology, 5, 197–220. DOI: 10.1146/annurev.
Wakefield, J.C. (2008). The perils of dimensionalization: clinpsy.032408.153542
Challenges in distinguishing negative traits from personality Widiger, T.A., & Simonsen, E. (2005). Alternative dimensional
disorders. The Psychiatric Clinics of North America, 31, 379–393. models of personality disorder. Journal of Personality
DOI: 10.1016/j.psc.2008.03.009 Disorder, 19, 110–130. DOI: 10.1521/pedi.19.2.110.62628
Weertman, A., Arntz, A., & Kerkhofs, M.L.M. (2000). SCID-II. Widiger, T.A., & Trull, T.J. (2007). Plate tectonics in the classification
Gestructureerd Klinisch Interview DSM-IV As-II Persoonlijkheidsstoor- of personality disorder: Shifting to a dimensional model. The
nissen. Amsterdam: Pearson. American Psychologist, 62, 71–83. DOI: 10.1037/0003-066X.62.2.71
Westen, D., & Shedler, J. (2000). A prototype matching ap- Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The
proach to diagnosing personality disorders toward DSM-V. prevalence of DSM-IV personality disorders in psychiatric
Journal of Personality Disorders, 14, 109–126. DOI: 10.1521/ outpatients. The American Journal of Psychiatry, 162, 1911–1918.
pedi.2000.14.2.109 DOI: 10.1176/appi.ajp.162.10.1911

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2012)
DOI: 10.1002/cpp